Men’s Health: Myths and Facts About Hormone Therapy

Discover the impact of men’s health in hormone therapy on overall wellness and its role in enhancing quality of life.

Abstract

Hello, I’m Dr. Alex Jimenez, and in this educational post, I will walk you through an easy-to-understand, evidence-based journey on erectile dysfunction (ED) and testosterone deficiency (low T), two common men’s health concerns that often present together. With my background in chiropractic (DC), as an Advanced Practice Registered Nurse (APRN), a Family Nurse Practitioner (FNP-BC), and with certifications in Functional Medicine (CFMP, IFMCP), Anti-aging and Regenerative Medicine (ATN), and Cranial Spinal Integration (CCST), I bring a multifaceted, integrative perspective to patient care. We will explore the latest findings on these conditions, delving into their causes, symptoms, and the diagnostic algorithms recommended by leading medical associations. I will explain the vascular and neural physiology of erections, the nitric oxide–cyclic GMP pathway, and how risk factors like metabolic disease, medications, and lifestyle choices impair erectile function. I will detail diagnostic steps, standardized assessments, and comprehensive treatment options, ranging from phosphodiesterase-5 inhibitors (PDE5i) and vacuum devices to intracavernosal injections, testosterone replacement therapy (TRT), off-label alternatives such as Clomid, and emerging modalities such as low-intensity shockwave therapy (LiSWT).

A key part of our approach at Injury Medical Clinic PA is our integrated model. I will explain how my role as a chiropractor and functional medicine practitioner complements the medical oversight provided by our Medical Director, Dr. Maria Guadalupe Cardenas, MD, to create a holistic and effective treatment plan. I highlight how Dr. Cardenas (Board Certified in Internal Medicine) (NPI #1164426749, Texas MD License #J2933), with over 40 years of experience, serves as our Medical Director and Collaborative Physician at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas, providing medical oversight alongside my chiropractic-led care. Throughout, I will present the latest findings from leading researchers, offer practical protocols rooted in modern, evidence-based methods, and use a brief case study to guide application to real practice. This journey will provide you with a clear roadmap to navigating these conditions and achieving better health outcomes.

Men’s Health Focus: Why Erectile Dysfunction and Low Testosterone Matter

I see men every week who are navigating concerns about erectile performance, libido, energy, and confidence. Though sensitive, these topics are best approached with clarity, empathy, and rigorous science. In the United States, ED affects about 30 million men, with prevalence rising with age. Globally, ED is projected to impact hundreds of millions of men, and yet only a fraction seek or receive treatment. My goal is to demystify ED and low T by explaining the physiology and then translating that knowledge into effective, personalized care.

Our Integrative Clinic Model in El Paso, Texas

At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas, we operate a multidisciplinary model that is common in modern integrative and injury care settings:

• Medical Direction: Maria Guadalupe Cardenas, MD (Internal Medicine), Board Certified, NPI #1164426749, Texas MD License #J2933, brings over 40 years of clinical experience as our Medical Director and Collaborative Physician. She oversees medical protocols, diagnostics, lab interpretation, cardiometabolic risk management, and safety when prescribing or coordinating medications or hormones. This partnership forms the cornerstone of our integrative care model, allowing us to seamlessly blend the structural and holistic focus of chiropractic care with the diagnostic and prescriptive authority of internal medicine.
• Chiropractic and Functional Medicine Care: I, Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, lead integrative chiropractic care, functional medicine assessments, musculoskeletal rehabilitation, nutritional therapeutics, and care coordination. I focus on the “why.” Using functional medicine principles, I investigate the root causes of hormonal imbalance. My chiropractic adjustments help optimize nervous system function, which is crucial for regulating the endocrine system. As a nurse practitioner, I can order labs, interpret results, and formulate comprehensive treatment plans.
• Personal Injury and Rehabilitation: Our team manages post-injury biomechanical dysfunction, pelvic and lumbar stabilization, and neurovascular rehabilitation that can impact sexual function.
• Connected Services: We incorporate physical therapy, health coaching, and referrals to urology, endocrinology, mental health, and pelvic floor therapy when appropriate.

This collaborative framework allows us to combine evidence-based medical oversight with manual therapy, lifestyle interventions, and advanced diagnostics, resulting in comprehensive, safe, and tailored care plans that address health from every angle. When a patient presents with symptoms, we don’t just see a number on a lab report; we see the whole person.

Unpacking the Issues: A Case Study

Let’s begin our journey by considering a typical case we often see in our clinic. I’ll refer to him as “Mister T.”

Mister T is a 56-year-old male presenting with several chronic conditions: hypertension, hyperlipidemia (high cholesterol), obesity, and obstructive sleep apnea (OSA). His primary complaints are persistent fatigue, a noticeable decline in physical performance and endurance, low libido, frustrating weight gain, and mild erectile dysfunction (ED).

His primary care provider had checked his testosterone, which came back at a low 150 ng/dL. However, a crucial detail is that this blood sample was taken in the afternoon. He has a CPAP machine for his sleep apnea but admits he isn’t compliant with using it. His SHIM score is 8 (moderate ED). Aside from these points, his physical exam was unremarkable. As we move through this discussion, keep Mister T’s case in mind. By the end, we’ll revisit his situation and outline a comprehensive, integrative treatment plan.

Understanding Erectile Dysfunction: The Physiology You Can Use

ED is defined as the consistent or recurrent inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance. The erection process is an elegant integration of vascular, neural, and endothelial function.

Key physiology:

• Neural Arousal and Nitric Oxide (NO): Sexual arousal activates parasympathetic pathways, releasing nitric oxide from nerve terminals and endothelial cells in penile tissue. NO stimulates soluble guanylate cyclase, increasing cyclic guanosine monophosphate (cGMP).
• cGMP and Smooth Muscle Relaxation: cGMP orchestrates smooth muscle relaxation in the corpus cavernosum, dilating arterioles, opening the lacunar spaces, and compressing venous outflow. This veno-occlusive mechanism sustains rigidity.
• Phosphodiesterase-5 (PDE5): PDE5 breaks down cGMP, terminating the erectile response. PDE5 inhibitors (like sildenafil and tadalafil) delay cGMP breakdown, enhancing erectile quality during arousal.
• Additional Modulators: Agents such as alprostadil (prostaglandin E1) and papaverine modulate smooth muscle tone via alternate intracellular pathways.

Why this matters: When endothelial function is impaired (e.g., from diabetes, hypertension, smoking), NO bioavailability drops, and cavernosal smooth muscle becomes less responsive, reducing rigidity and durability of erections.

Risk Factors That Undermine Erectile Function

I counsel patients that ED is often a systemic signal. Common contributors include:

• Cardiometabolic: Hypertension, diabetes, dyslipidemia, obesity, metabolic syndrome. Endothelial dysfunction and arterial stiffness reduce NO production and cavernosal inflow (Burnett & Nehra, 2015).
• Medications: SSRIs, thiazide diuretics, some beta-blockers, and centrally acting agents can blunt libido, arousal, or vascular response (Khera et al., 2016).
• Neurogenic: MS, spinal cord injuries, peripheral neuropathy.
• Hormonal: Low testosterone can impair libido and nocturnal erections and may worsen response to PDE5 inhibitors in some men (Corona et al., 2014).
• Substance Use: Alcohol, nicotine, opioids, and stimulants can acutely and chronically impair erectile physiology and neurovascular coupling.
• Psychosocial: Performance anxiety, relationship stress, depression. Psychogenic ED often coexists with vasculogenic ED; treating both yields better outcomes.

Understanding Low Testosterone (Hypogonadism)

Men often ask about low T because fatigue, reduced libido, diminished muscle mass, mood changes, and impaired sexual function impact quality of life. Hypogonadism is clinically defined as a syndrome that arises from the failure of the testes to produce physiological concentrations of testosterone.

It’s a natural part of aging for men to experience a gradual decline in testosterone, typically at about 1-2% per year. Research indicates that the prevalence of TD increases with age. Charles et al. (2018) reported the following statistics:

• 50s: 13% of men have low testosterone.
• 60s: 19% of men.
• 70s: 28% of men.
• 80s: 49% of men.

The market for low testosterone treatments has exploded. Sales quadrupled between 2000 and 2011, with the global market reaching $1.6 billion annually. It’s projected to hit $2.2 billion by 2027. This popularity, however, has led to some concerning practices. Alarmingly, about one-third of men currently on testosterone therapy do not meet the clinical criteria for deficiency, and a staggering 25% were never even tested before starting treatment (Handelsman, 2013). This highlights the critical need for proper diagnosis and evidence-based management.

What Causes Low Testosterone?

Testosterone deficiency can be categorized as primary or secondary.

Primary Hypogonadism: Issues with the Testes

Primary causes stem from a problem directly within the testicles.

• Aging: The natural decline in testicular function over time.
• Direct Damage: Trauma or injury to the testicles.
• Medical Treatments: Chemotherapy or radiation can damage testicular cells.
• Surgical Removal: Orchiectomy (removal of one or both testicles).
• Autoimmune Diseases: The body’s immune system mistakenly attacks testicular tissue.
• Genetic Conditions: Such as Klinefelter syndrome.

Secondary Hypogonadism: Issues with Brain Signaling

Secondary causes arise from problems with the pituitary gland or hypothalamus in the brain, which signal the testes to produce testosterone.

• Obesity: Excess body fat, particularly visceral fat, contains high levels of the enzyme aromatase, which converts testosterone into estrogen, thereby lowering free testosterone levels.
• Type 2 Diabetes: Metabolic dysfunction associated with diabetes can impair the signaling pathway from the brain to the testes.
• Obstructive Sleep Apnea (OSA): Disrupted sleep and oxygen deprivation put immense stress on the body, disrupting the hypothalamic-pituitary-gonadal (HPG) axis. In my practice, I always emphasize that before we even consider TRT for a patient with OSA, they must be religiously compliant with their CPAP machine for at least three months. We then recheck their testosterone levels, as correcting sleep apnea can often significantly improve natural testosterone production.
• Medications: Certain drugs, particularly opioids and glucocorticoids, can suppress the HPG axis.
• Excessive Alcohol Use: Alcohol is toxic to the Leydig cells in the testes, which are responsible for producing testosterone.

The Diagnostic Pathway for ED and Low Testosterone

Proper diagnosis is paramount. I start with a comprehensive history and targeted physical exam followed by standardized questionnaires. This enhances patient comfort and gives us objective data for tracking progress. The American Urological Association (AUA) provides a clear algorithm that we follow in our clinic (Mulhall et al., 2018).

1. Standardized Tools & History:

• • International Index of Erectile Function (IIEF-15): Broad domains; scores help characterize severity and treatment response (Rosen et al., 1997).
  • Sexual Health Inventory for Men (SHIM): A concise 5-item version; practical for routine visits.

• Physical Exam: A focused male GU exam, prostate exam when indicated, vascular assessment, and signs of hypogonadism or metabolic disease.
• Initial Lab Work: A formal diagnosis of testosterone deficiency (TD) requires two separate morning testosterone measurements, each below 300 nanograms per deciliter (ng/dL), coupled with one or more classic symptoms. We measure a morning total testosterone level. Testosterone levels are highest in the morning, so an afternoon draw, like Mister T’s, is often inaccurate and can be falsely low. If this morning level is greater than 300 ng/dL, we typically look for other causes for the patient’s symptoms.
• Confirmation and Further Testing: If the initial morning level is below 300 ng/dL, we repeat the test to confirm the finding. At this time, we also order a more comprehensive panel, including:

• • Free Testosterone or SHBG if binding issues are suspected (Bhasin et al., 2018).
  • Luteinizing Hormone (LH): This hormone from the pituitary gland tells the testes to make testosterone. It helps us differentiate between primary (high LH) and secondary (low or normal LH) hypogonadism.
  • Fasting glucose/HbA1c, lipid panel.
  • Hematocrit: This measures the percentage of red blood cells in whole blood. Testosterone can increase red blood cell production (erythrocytosis). A baseline is crucial before starting therapy.
  • Prostate-Specific Antigen (PSA): A baseline screen for prostate health.
  • TSH/thyroid panel if symptoms suggest thyroid involvement.

• Interpreting the Results:

• • If hematocrit is elevated (over 50%), we must first investigate the cause (e.g., untreated sleep apnea) before considering TRT.
  • If prolactin levels are significantly elevated (over 25 ng/mL), this could indicate a pituitary tumor (prolactinoma), and an MRI of the pituitary and a referral to an endocrinologist are necessary.

Rationale: We need to identify reversible drivers (e.g., uncontrolled diabetes) and safely select interventions. Morning testosterone prevents underestimating hypogonadism due to diurnal troughs.

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Treatment Pathways: Evidence-Based and Patient-Centered

I align therapies with severity, comorbidities, preferences, and safety. Shared decision-making is critical. The foundation of any treatment plan begins with lifestyle modifications.

Phosphodiesterase-5 inhibitors (PDE5i)

• What they do: Increase cavernosal cGMP, enhance smooth muscle relaxation, improve inflow during arousal.
• How to use:

• • Sildenafil: On-demand, typically 50–100 mg, taken approximately 1 hour before activity; avoid fatty meals to maintain efficacy (Khera et al., 2016).
  • Tadalafil: Flexible dosing; 5 mg daily or 10–20 mg on-demand 1–2 hours before activity; longer half-life allows spontaneity.

• Why they may fail: Severe endothelial dysfunction (e.g., post-prostatectomy neuropraxia, uncontrolled diabetes), inadequate stimulation, or incorrect dosing/timing.
• Safety: Avoid with nitrates (risk of severe hypotension) and use caution with alpha-blockers; counsel on headache, flushing, dyspepsia, nasal congestion.

Navigating Testosterone Replacement Therapy (TRT)

When lifestyle changes aren’t enough, and low T is confirmed, TRT is the primary therapy. It is a Schedule III controlled substance and comes in several forms.

• Intramuscular Injections: The most common and affordable form.

• • Formulations: Testosterone cypionate and testosterone enanthate.
  • Dosing: A typical starting dose is 75-100 mg weekly or 150-200 mg every two weeks.
  • Pros and Cons: Injections are effective but create “peaks and valleys.” Patients often feel great for a few days after the injection (the peak) but may experience a return of symptoms as their levels drop before the next dose (the valley).

• Pellets (Testopel): Small, crystalline pellets of testosterone implanted under the skin of the buttock every 3-6 months.

• • Dosing: An initial dose might involve implanting six pellets, totaling 450 mg of testosterone.
  • Pros and Cons: Pellets provide a very steady release of testosterone. The procedure is minor but must be performed in the office. In my clinical experience, most men need a reimplantation every 3-4 months.

• Topical Gels (AndroGel, Fortesta): Applied daily to the skin.

• • Dosing: A typical starting dose is 50 mg daily.
  • Pros and Cons: Gels provide stable, consistent daily levels. The major drawback is the risk of transference to women and children, which has a black box warning.

• Oral and Nasal Formulations: Less common due to cost and side effects.

• • Oral (Jatenzo, Tlando): Expensive and have a black box warning for increasing blood pressure and risk of cardiovascular events.
  • Nasal (Natesto): Can cause nasal irritation and has a risk of transference. I do not have any patients currently using this form.

Monitoring and Managing Side Effects of TRT

Starting TRT requires diligent monitoring.

• Labs: We check testosterone and hematocrit levels within the first three months of therapy and then every 6-12 months. The goal is a testosterone level of 450-650 ng/dL.
• Erythrocytosis: The most common side effect I see clinically. Testosterone stimulates red blood cell production. If hematocrit rises above 52-54%, it increases the risk of clots. We manage this by adjusting the dose or therapeutic phlebotomy (donating blood).
• Contraindications: We do not prescribe TRT to men with active prostate or breast cancer, untreated severe sleep apnea, a hematocrit over 50-54%, severe heart failure, or a recent heart attack or stroke. Crucially, TRT suppresses sperm production (spermatogenesis) and is not for men actively trying to conceive.

Alternative and Second-Line Therapies

Clomiphene (Clomid)

Clomid is an off-label medication we use frequently, especially for younger men who wish to preserve fertility.

• Mechanism: It’s a selective estrogen receptor modulator (SERM) that blocks estrogen receptors in the brain, tricking the brain into increasing LH and FSH. This stimulates the testes to produce more testosterone and more sperm.
• Dosing: A common regimen is 25 mg every other day or 50 mg three times a week.
• Who is a good candidate? A younger man planning a family or someone averse to TRT who accepts a more modest boost in testosterone levels.

Vacuum Erection Devices (VED)

• Mechanism: Negative pressure draws blood into the penis; a constriction ring maintains rigidity.
• Use case: Men with limited response to PDE5i or for combination therapy.
• Pros/cons: Non-invasive but can be cumbersome; potential penile discomfort.

Urethral Suppositories (Alprostadil, MUSE)

• Mechanism: Local prostaglandin E1 dilates cavernosal vasculature.
• Considerations: Rapid onset; cost and urethral discomfort are common discontinuation reasons.

Intracavernosal Injections (ICI)

• FDA-approved: Alprostadil (Caverject, Edex).
• Compounded options: Bimix (phentolamine + papaverine), Trimix (+ alprostadil). Not FDA-approved; require a reputable compounding pharmacy.
• Dosing: Start low and titrate; an office test dose is essential.
• Risks: Priapism; instruct patients on management and to seek urgent care if unresolved.

Penile Prosthesis

• Indication: Refractory ED after conservative measures have failed.
• Types: Inflatable devices with high satisfaction rates (>90%).
• Pros: Reliable rigidity, control. Restores functional mechanics independent of endothelial or neurogenic limitations.
• Cons: No spontaneous erections; slight length changes for some; low infection risk.

Emerging Therapies and Integrative Strategies

Low-Intensity Shockwave Therapy (LiSWT)

• Mechanism: Pulsed acoustic energy induces microtrauma that stimulates angiogenesis and tissue remodeling, potentially improving cavernosal hemodynamics (Lu et al., 2017).
• Evidence: Promising for mild-to-moderate vasculogenic ED; remains investigational in many jurisdictions (Khera et al., 2023).
• Practical notes: Series-based treatments; not typically covered by insurance.

Online/Concierge and OTC Options

• Compounded online platforms: Compounded drugs are not FDA-approved and may vary in quality; I advise caution and medical oversight (FDA, 2020).
• OTC topical gel (e.g., Eroxon): Marketed to induce rapid thermosensory changes. Effectiveness varies; sustained rigidity relies on deeper cavernosal pathways.

Other Emerging & Nutraceutical Therapies

• PRP and stem cell therapies: Currently investigational with limited evidence; not FDA-approved for ED (Khera et al., 2023).
• Hyperbaric Oxygen Therapy (HBOT): May enhance perfusion; evidence is preliminary.
• Nutraceuticals: Agents such as L-arginine and L-citrulline can modestly support NO pathways. While no food will magically double your testosterone, specific nutrients are vital. Zinc and Selenium are essential for testicular function. The market is flooded with “testosterone boosters” like Nugenix that often contain these minerals but are expensive and based on weak evidence. I advise my patients to take a high-quality men’s multivitamin instead, which is more cost-effective and provides a better foundation for health.

Integrative Chiropractic Care: Biomechanics, Autonomics, and Pelvic Health

Integrative chiropractic care is often overlooked in sexual health, yet I routinely observe significant benefits:

• Lumbopelvic Biomechanics: Lumbar and sacroiliac joint dysfunction, hip mobility limitations, and core instability alter pelvic floor tone and neural signaling, potentially affecting penile hemodynamics.
• Autonomic Balance: Gentle, patient-specific manual therapies and breathing retraining can reduce sympathetic overdrive and enhance parasympathetic tone—thereby supporting NO-mediated arousal and vasodilation.
• My Clinical Observations: From years of practice in El Paso and insights shared on my website and professional profile, men with chronic low back pain, gluteal inhibition, and tight hip flexors often report improved erectile quality after targeted pelvic stabilization, gluteal activation, and thoracolumbar mobility work. When combined with metabolic optimization, responses to PDE5i improve and spontaneous rigidity becomes more reliable.
• Protocol Elements:

• • Mobility: Hip extension drills, thoracolumbar rotation work.
  • Strength: Progressive gluteal and core conditioning.
  • Neuromodulation: Diaphragmatic breathing, vagal tone support, stress reduction.

Functional Medicine and Personal Injury Integration

Under Dr. Cardenas’ medical oversight, we implement functional medicine strategies to address root contributors:

• Nutrition: Mediterranean-style dietary patterns improve endothelial function (Esposito et al., 2004).
• Glycemic Control: Lower A1c improves cavernosal responsiveness.
• Sleep and Stress: Sleep apnea screening and stress management can restore hormonal and autonomic balance.
• Personal Injury Care: Men recovering from motor vehicle collisions or falls can have pelvic/lumbar trauma impacting neural pathways. Our integrated rehabilitation aims to restore normal movement patterns, reduce neurogenic irritation, and rebuild confidence.

Revisiting Mister T: An Integrative Treatment Plan

Now, let’s follow up with our 56-year-old patient. Here is the integrative plan we would develop at our clinic:

1. Address the Root Causes:

• • CPAP Compliance: The first step is to ensure he uses his CPAP every night for 3 months straight. This is non-negotiable.
  • Lifestyle Overhaul: We would enroll him in our functional health program, focusing on an anti-inflammatory diet and a personalized exercise plan with resistance and cardiovascular training.

• Proper Diagnostic Workup: We would immediately order fasting morning total and free testosterone levels, along with LH, hematocrit, PSA, and a full metabolic and lipid panel to establish an accurate baseline.
• Chiropractic and Rehabilitative Care: I would perform a full spinal evaluation. Adjustments to the thoracic and lumbar spine can improve nerve flow to the adrenal glands and reproductive organs. Rehabilitative exercises would be prescribed to improve physical performance.
• Symptom Management: For his immediate complaint of mild ED, with Dr. Cardenas’s medical clearance, we could offer a trial of tadalafil 5 mg daily with pulse dosing before activity. We could also consider a LiSWT series to augment cavernosal perfusion and add a VED if needed for venous occlusion support.
• Re-evaluation: After three months of consistent CPAP use and lifestyle changes (around 2026-08-07), we would repeat his morning testosterone test and SHIM score. If his levels remain clinically low and symptoms persist despite these interventions, and he has no contraindications, we would then have a detailed discussion about initiating TRT (perhaps starting with injections or a gel) or trying a course of Clomid, all under the careful medical supervision of Dr. Cardenas.

By taking this step-by-step, patient-centered, and integrated approach, we address not just the low number but the entire web of interconnected factors contributing to Mister T’s poor health, setting him on a path to recapture his vitality truly.

Closing Thoughts

ED and low T are more than isolated symptoms—they reflect whole-person physiology. By combining medical oversight from an experienced internist such as Dr. Maria Guadalupe Cardenas with integrative chiropractic care, functional medicine, and well-structured rehabilitation, we offer men a comprehensive, evidence-based pathway to improved sexual health and overall vitality. My clinical experience continues to confirm that when we restore endothelial health, pelvic biomechanics, and autonomic balance, men achieve stronger, more reliable erections and greater confidence. Our mission in El Paso is to deliver precision, compassion, and measurable results.

References

• AUA Guideline on Erectile Dysfunction (Khera, M., Goldstein, I., et al., 2016). American Urological Association.
• AUA Update on ED and Regenerative Therapies (Khera, M., et al., 2023). American Urological Association Journals.
• Charles, J., Harrison, C., & Britt, H. (2018). Management of male hypogonadism in general practice. Australian Prescriber, 41(1), 19–23.
• Evaluation and management of testosterone deficiency: AUA guideline. The Journal of Urology, 200(5), 1023- 1039. (Mulhall, J. P., Trost, L. W., et al., 2018).
• FDA: Compounded Drugs and Approval Status (U.S. Food and Drug Administration, 2020).
• Global trends in androgen use and abuse. Current Opinion in Endocrinology, Diabetes and Obesity, 20(3), 246–254. (Handelsman, D. J., 2013).
• Low-Intensity Shockwave Therapy for Erectile Dysfunction: Mechanisms and Evidence (Lu, Z., Lin, G., et al., 2017). Sexual Medicine Reviews.
• Mediterranean Diet and Endothelial Function (Esposito, K., Marfella, R., et al., 2004). New England Journal of Medicine.
• Oxidative Stress and Nitric Oxide in Erectile Dysfunction (Burnett, A. L., & Nehra, A., 2015). Journal of Sexual Medicine.
• Testosterone and Erectile Function: Clinical Interactions (Corona, G., Isidori, A. M., et al., 2014). The Journal of Clinical Endocrinology & Metabolism.
• Testosterone Therapy in Men With Hypogonadism: Endocrine Society Clinical Practice Guideline (Bhasin, S., Brito, J. P., et al., 2018). The Journal of Clinical Endocrinology & Metabolism.

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